Stabilization apparatuses and methods for medical procedures

ABSTRACT

The present invention teaches minimally invasive apparatuses and methods for stabilizing and/or guiding medical instruments used in a variety of medical procedures, including (a) introducing one or more substances into a subject&#39;s body, (b) removing one or more substances from a subject&#39;s body, (c) manipulating a region of a subject&#39;s body, or (d) combinations thereof. Among the many advantages of the inventive apparatuses are their simplicity and adaptability to attach to a variety of retractors.

CROSS-REFERENCE TO RELATED APPLICATION

This non-provisional application claims the priority benefit of U.S.Provisional Patent Application No. 61/817,785, filed on Apr. 30, 2013,which is incorporated herein by reference in its entirety.

FIELD OF THE INVENTION

The present invention generally relates to apparatuses for medicalprocedures, and methods of use thereof.

BACKGROUND

All publications herein are incorporated by reference to the same extentas if each individual publication or patent application was specificallyand individually indicated to be incorporated by reference. Thefollowing description includes information that may be useful inunderstanding the present invention. It is not an admission that any ofthe information provided herein is prior art or relevant to thepresently claimed invention, or that any publication specifically orimplicitly referenced is prior art.

When physicians are performing procedures on or around certain areas ofthe body such as the spinal cord, brain, and joints, very precise,controlled, and stable manipulations are often required to avoid patientinjury and to optimize outcome. There is a need in the art forapparatuses and methods that will improve the safety and accuracy ofperforming certain medical procedures in those areas.

More specifically, certain medical procedures performed by physiciansare associated with especially high risks of accidental patient injuryand/or treatment failure, due to a combination of the nature of thetissues involved in the procedure, the high degree of accuracy demandedby the procedure, limitations of existing surgical instruments(including stabilizing apparatuses), limitations associated with thefield of view, and human error. In order to increase the likelihood of afavorable outcome, a number of attempts have been made to improve uponthe stabilizing apparatuses used in conjunction with a number of medicalinstruments for a variety of different surgical procedures, includingthose involving the introduction of a substance into or removal of asubstance from a delicate area of a patient's body. Exemplarystabilizing apparatuses known in the art include the Spinal Derrick, theWarner Device, and the Brundobler Device. Unfortunately, these devicesare all either difficult to use (requiring a large amount of physiciantraining), have an excessive part count (thereby carrying a relativelyhigh risk of equipment failure or patient injury), or have significantproblems related to positioning. For example the Spinal Derrick deviceused for spinal surgery comprises over 50 parts, making its assemblylong and difficult, and leading to an increased risk of one of its partsfalling into the incision and causing spinal cord trauma. Additionally,this device lacks accurate scales, and requires the use of fourpercutaneous posts that are placed “blindly,” further increasing therisk of spinal cord injury, infection, and bleeding (partly due to thefour additional incisions required).

SUMMARY OF THE INVENTION

In various embodiments, the invention teaches an apparatus that includesa securing arm that includes a first end, a second end, a long axis, anda short axis; a connecting arm that includes a first end, a second end,a long axis, and a short axis; a positioning arm that includes a firstend, a second end, a long axis, and a short axis; and a guiding arm thatincludes a first end, a second end, a long axis, and a short axis;wherein (1) the first end of the connecting arm is attached to thesecond end of the securing arm, (2) the second end of the connecting armis attached to the first end of the positioning arm, (3) the long axisof the connecting arm is perpendicular to the long axis of each of thesecuring arm and positioning arm, (4) the first end of the securing armand the second end of the positioning arm can be positioned to extend insubstantially the same direction away from the connecting arm, (5) thepositioning arm is attached at its second end to the second end of theguiding arm, such that the positioning arm and guiding arm areperpendicular to one another, and (6) the guiding arm can be positionedsuch that the axis along which its long axis is situated isperpendicular to but does not intersect with the axes along which thelong axis of the securing arm and the long axis of the connecting armare respectively situated. In some embodiments, the securing arm furtherincludes one or more clamps on its first end, and the one or more clampsare configured to attach to an arm of a tissue retractor. In someembodiments, the guiding arm further includes an instrument attachingcomponent configured to slide along the long axis of the guiding arm. Insome embodiments, the instrument attaching component includes one ormore clamps configured to clamp a medical instrument. In certainembodiments, the sliding motion of the instrument attaching component iscontrolled by a dial situated at the first end of the guiding arm. Insome embodiments, the connecting arm includes elongated nesting elementsthat allow for telescoping motion in the direction of its long axis,such that the length of the connecting arm can be increased ordecreased. In certain embodiments, the positioning arm includeselongated nesting elements that allow for telescoping motion in thedirection of its long axis, such that the length of the positioning armcan be increased or decreased. In some embodiments, the telescopingmotion of the connecting arm is controlled by rotation of a dialsituated at its second end. In certain embodiments, the telescopingmotion of the positioning arm is controlled by rotation of a dialsituated at its first end. In certain embodiments, the medicalinstrument is selected from the group consisting of: a cannula, a biopsyneedle, a needle, a tube, a cauterization device, a laser, a drill, anendoscope, a guidewire, a fiberoptic device, an electrode, a saw, anultrasonic device, a spectroscopic device, a camera, an electricalsensor, a thermal sensor, a catheter, a draining tube, and combinationsthereof. In some embodiments, the apparatus further includes a sideclamp attached to the securing arm, wherein the side clamp is configuredto attach to an elongated object. In some embodiments, the securing armis removably attached to the connecting arm. In various embodiments, thepositioning arm is removably attached to the connecting arm and/or theguiding arm. In some embodiments, the side clamp is removably attachedto the securing arm. In certain embodiments, the elongated object is adevice selected from the group consisting of: a liquid reservoir, a gasreservoir, a pump, an imaging device, and combinations thereof.

In various embodiments, the invention teaches a system. In someembodiments, the system includes any apparatus described above and atissue retractor attached to the securing arm of the apparatus by one ormore clamps of the securing arm. In some embodiments, the system furtherincludes an instrument attached to the instrument attaching component,wherein the instrument is selected from the group consisting of: acannula, a biopsy needle, a needle, a tube, a cauterization device, alaser, a drill, an endoscope, a guidewire, a fiberoptic device, anelectrode, a saw, an ultrasonic device, a spectroscopic device, acamera, an electrical sensor, a thermal sensor, a catheter, a drainingtube, and combinations thereof. In some embodiments, the instrumentincludes a cannula with a needle situated at the end thereof. In someembodiments, the cannula and needle are configured to inject cells intoa region of interest in a subject's body. In various embodiments, thecannula contains a quantity of neural progenitor cells. In someembodiments, the neural progenitor cells express glial cell line derivedneurotrophic factor. In certain embodiments, the region of interest isthe subject's spine. In some embodiments, the system further includes aliquid reservoir and a pump connected thereto, wherein the liquidreservoir and pump are attached to the side clamp.

In various embodiments, the invention teaches a method for performing asurgical procedure on a subject. In some embodiments, the methodincludes attaching any apparatus described herein above to an arm of atissue retractor that is engaged in an incision in the subject's body,and guiding a medical instrument attached to the guiding arm of theapparatus through the incision in the subject's body. In certainembodiments, the medical instrument is a cannula with a needle situatedat the end thereof. In some embodiments, the cannula and needle areconfigured to inject cells into a region of interest in the subject'sbody. In some embodiments, the region of interest is the subject'sspine. In some embodiments, the cells are neural progenitor cells. Insome embodiments, the subject has been diagnosed with amyotrophiclateral sclerosis (ALS). In various embodiments, the method furtherincludes performing imaging of the region of interest in the subject'sbody. In some embodiments, the imaging performed is selected from thegroup consisting of computed tomography (CT), magnetic resonance imaging(MRI), ultrasound, and combinations thereof. In some embodiments, themethod further includes injecting neural progenitor cells expressingglial cell line derived neurotrophic factor into the subject's spine.

BRIEF DESCRIPTION OF THE DRAWINGS

Exemplary embodiments are illustrated in the referenced figures. It isintended that the embodiments and figures disclosed herein are to beconsidered illustrative rather than restrictive.

FIG. 1A depicts, in accordance with an embodiment of the invention,stereotactic apparatus 100. Stereotactic apparatus 100 is clamped to arm301 of tissue retractor 300. Cylindrical object 400 is fastened tostereotactic apparatus 100 by side clamp 6000. FIG. 1B depictsstereotactic apparatus 100 without attachment to a tissue retractor.FIG. 1C depicts stereotactic apparatus 200. FIG. 1D depicts stereotacticapparatus 100 attached to cylindrical object 400 and tissue retractor300. Instrument 7000 is shown attached to guiding arm 1000 ofstereotactic apparatus 100, and extending downward along the z-axisbetween the arms of tissue retractor 300.

FIG. 2A depicts, in accordance with an embodiment of the invention,stereotactic apparatus 100. Tissue retractor 300 and cylindrical object400 are shown. FIG. 2B depicts an alternate view of stereotacticapparatus 100. FIG. 2C depicts an alternate view of stereotacticapparatus 200.

FIG. 3 depicts, in accordance with an embodiment of the invention, apartially exploded view of stereotactic apparatus 100.

FIG. 4 depicts, in accordance with an embodiment of the invention, apartially exploded view of stereotactic apparatus 100.

FIG. 5 depicts, in accordance with an embodiment of the invention,loosening knob 114 allows for adjustment of the position of positioningarm 2000 along the x-axis.

FIG. 6 depicts, in accordance with an embodiment of the invention,loosening screw 135 allows for adjustment of the position of positioningarm 2000 along the y-axis.

FIG. 7 depicts, in accordance with an embodiment of the invention,loosening knob 130 allows for adjustment of the position of cylindricalobject 400 along the x-axis.

FIG. 8 depicts, in accordance with an embodiment of the invention,loosening of knob 114 allows for rotation of positioning arm 2000 aroundthe x-axis and associated motion of guiding arm 1000 along the y-zplane.

FIG. 9 depicts, in accordance with an embodiment of the invention,loosening screw 135 allows for rotation of cross clamp 132 around they-axis, and associated motion of guiding arm 1000 along the x-z plane.

FIG. 10 depicts, in accordance with an embodiment of the invention,rotating dial 116 causes telescoping of inner nesting element 112 ofpositioning arm 2000. FIG. 10 also shows rotating dial 101 causes motionof instrument attachment component 107 along the z-axis.

FIG. 11 depicts, in accordance with an embodiment of the invention,rotating dial 131 causes telescoping motion of inner nesting element 119of connecting arm 3000.

FIG. 12 depicts, in accordance with an embodiment of the invention, apartially exploded view of connecting arm 3000. Arrows labeled “14A”indicate the cross section represented in FIG. 14A.

FIG. 13 depicts, in accordance with an embodiment of the invention, anexploded view of a portion of connecting arm 3000.

FIG. 14A depicts. in accordance with an embodiment of the invention, across-sectional view of the long axis of connecting arm 3000. FIG. 14Bdepicts a cross-sectional view of the short axis of connecting arm 3000.

FIG. 15 depicts, in accordance with an embodiment of the invention, apartially exploded view of positioning arm 2000. Arrows labeled “17A”indicate the cross section represented in FIG. 17A.

FIG. 16 depicts, in accordance with an embodiment of the invention, apartially exploded view of a portion of positioning arm 2000.

FIG. 17A depicts, in accordance with an embodiment of the invention, across-sectional view of the long axis of positioning arm 2000. FIG. 17Bdepicts, in accordance with an embodiment of the invention, a crosssectional view of the short axis of positioning arm 2000.

FIG. 18 depicts, in accordance with an embodiment of the invention, anexploded view of guiding arm 1000. Arrows labeled “19” indicate thecross section represented in FIG. 19.

FIG. 19 depicts, in accordance with an embodiment of the invention, across-sectional view of the long axis of guiding arm 1000.

FIG. 20 depicts, in accordance with an embodiment of the invention, anexploded view of side clamp 6000, and it's attachment to securing arm4000.

FIG. 21 depicts, in accordance with an embodiment of the invention, analternate exploded view of securing arm 4000.

FIG. 22 depicts, in accordance with an embodiment of the invention, sideclamp 6000.

FIG. 23 depicts, in accordance with an embodiment of the invention,scales 381, 382, and 383 on device 300. Device 300 is identical todevice 100 with respect to all other features.

DETAILED DESCRIPTION OF THE INVENTION

All references cited herein are incorporated by reference in theirentirety as though fully set forth. Unless defined otherwise, technicaland scientific terms used herein have the same meaning as commonlyunderstood by one of ordinary skill in the art to which this inventionbelongs. Szycher's Dictionary of Medical Devices CRC Press, 1995, mayprovide useful guidance to many of the terms and phrases used herein.One skilled in the art will recognize many methods and materials similaror equivalent to those described herein, which could be used in thepractice of the present invention. Indeed, the present invention is inno way limited to the methods and materials specifically described.

In some embodiments, properties such as dimensions, shapes, relativepositions, and so forth, used to describe and claim certain embodimentsof the invention are to be understood as being modified by the term“about.”

With the aforementioned shortcomings of previously existing technologiesin mind, the inventors developed novel stabilizing apparatuses andmethods of use thereof. While one of skill in the art would readilyappreciate that there are many possible applications of the apparatusesdescribed herein, certain embodiments are especially useful forprocedures performed on or around the spinal cord, including delivery ofcutting edge cellular and molecular therapies thereto. Importantly, allversions of the devices described herein also render the use ofpercutaneous posts unnecessary and therefore allow for a minimallyinvasive surgical approach.

Although numerous embodiments of stereotactic apparatuses are describedherein, there are certain features common to all of them. First, eachapparatus includes one or more components that make up a “securingsection” capable of stably connecting to an arm of a tissue retractingdevice. The second feature common to each of the apparatuses describedherein is a “positioning section,” which includes one or more componentscapable of positioning an instrument over a desired location in asubject's body. The third common feature is a “connecting section,”which serves to operably connect the positioning section and thesecuring section. A fourth common feature is a “guiding section,” whichcan be used to guide an instrument into or remove an instrument from asubject's body.

Provided below are descriptions of various components, combinations ofcomponents, and configurations of components relative to one anotherthat can be used to arrive at each of the common sections describedabove. Additional features that can be added to the stereotacticapparatus are also described.

Securing Section

In some embodiments, the securing section of the stereotactic apparatusis configured to removably attach to an arm of a tissue retractor.Removable attachment can be accomplished in any of a number of ways,using a wide range of components and combinations thereof. Merely by wayof non-limiting examples, the securing section could attach to the armof a tissue retractor by using one or more clasps, one or more clamps,one or more magnets, one or more screws, one or more pins, one or moreslot and groove arrangements, one or more straps, combinations thereofand the like. Therefore, each of these components, and modified versionsthereof, are within the scope of the invention. It is furthercontemplated that the attaching portion of the apparatus could beconfigured to attach to any of a variety of types of equipment thatmight be found in a setting in which a medical procedure is performed,including, but in no way limited to a table, a lamp, a brace, a tray,imaging equipment, and the like. It is also contemplated that the devicecould be configured for use in a non-surgical setting, in which it maybe used to perform any objective that requires the use of precisionguidance. It is also contemplated that the device could be scaledappropriately for such objectives.

In some embodiments, a clamping mechanism is incorporated on thesecuring arm, and used to attach the stereotactic apparatus to the armof a tissue retractor. One of skill in the art would readily appreciatethat numerous types of clamping mechanisms are suitable to accomplishthis function. One non-limiting example is depicted in FIG. 3, whichshows clamping mechanism 5000 of securing arm 4000 can be used to clamparm 301 of tissue retractor 300 (partially shown). A more detailed viewof the clamping components of this particular embodiment is shown inFIG. 21, and the individual components (and their functions) arethoroughly described in the examples section.

Importantly, the clamping mechanism shown in FIG. 21 can be used tosecurely and removably attach a stereotactic apparatus (includingstereotactic apparatus 100) to the arm of a number of different types oftissue retractors. Non-limiting examples of retractors to which theclamping mechanism can attach include the Mast Quadrant Retractor System(Medtronic), the MARS Retractor System (Globus Medical), the SpyderRetractor System (Aesculap), the Ravine Retractor System (K2M), theSynframe Retractor System (DePuy Synthes), and the Luxor RetractorSystem (Stryker). One of skill in the art would readily appreciate thatany retractor with one or more arms similar to those retractorsdescribed above could also be used in conjunction with the inventivestereotactic apparatuses described herein. One of skill in the art wouldfurther appreciate that the alternative attaching mechanisms describedabove would allow for the attachment of the securing section of anapparatus to one or more arms of alternative retractor devices that arenot specifically listed above.

Positioning Section

The purpose of the positioning section is to allow for stablepositioning of an instrument over a desired anatomical location, bypositioning a guiding arm to which the instrument is attached. One ofskill in the art would readily appreciate that there are many possiblecomponents and configurations thereof that could make up a positioningsection of the stereotactic apparatus. In certain embodiments thepositioning section includes components that allow for telescopingmotion, which permits fine adjustment of the position of the instrumentattached to the guiding arm. In some embodiments, a positioning arm isused. In various embodiments, the positioning arm includes two or morenested elements that are operably connected to one another as well as aninput component (e.g., a dial) in a manner that allows for telescopingmotion. In a non-limiting example, the telescoping motion isaccomplished by the components depicted in FIGS. 15-17. The interactionbetween and operation of the components of FIGS. 15-17 are thoroughlydescribed in the examples section.

One of skill in the art would readily appreciate that there are numerouspossible ways of stabilizing and controlling the telescoping motion ofthe positioning aim. Merely by way of non-limiting example, if amechanism with a threaded shaft is used, as depicted in FIGS. 15-17, thenumber of threadings on the shaft and the pitch of the threadings can beused to dictate the degree to which the positioning arm telescopes inresponse to associated input (e.g. rotation of a dial). In certainembodiments, the positioning arm is stabilized through the use ofcomponents that limit its range of motion in all but the axis alongwhich it is advanced or retracted. Merely by way of non-limitingexample, FIG. 16 shows the configuration of guiding set screws 176 a and176 b and supporting elements 178 a and 178 b is used to apply pressureon L-shaped tracks 179 a and 179 b of inner nested element 112 ofpositioning arm 2000. FIG. 16 also shows that screw 175 is positioned onthe opposite side of set screws 176 a and 176 b, in order to add to thestability of inner nested component 112, especially while it is beingextended or retracted.

One of skill in the art would readily appreciate that there are manypossible ways of attaching the positioning arm to the guiding arm. Asshown in FIG. 3, one way positioning arm 2000 can be connected toguiding arm 1000 is through the use of screw 133 that traverses theshort axis of guiding arm 1000 and connects to grooved receiving socket134.

Connecting Section

The long axis of the connecting section of the stereotactic apparatuscan be configured to be perpendicular to the long axis of the securingsection and the positioning section. In some embodiments, the connectingsection, like the positioning section, is a telescoping arm. In someembodiments, the telescoping connecting arm can be stabilized andcontrolled by any of the aforementioned components associated with thepositioning section. Merely by way of non-limiting example, telescopingof the connecting arm can be accomplished through the use of thecomponents shown in FIGS. 12-14, the interaction between which andfunction of which are thoroughly described in the examples section.

Guiding Section

The guiding section can be configured to allow for the attachment of oneor more instruments that can be extended into and retracted from asubject's body. In some embodiments, the guiding section includes aguiding arm. There are many possible ways by which an instrument can beattached to a guiding arm. One of skill in the art would readilyappreciate that the possible components that could be used to attach aninstrument to a guiding arm would vary depending upon the dimensions andnature of the instrument to be attached. Merely by way of non-limitingexamples, attachment of various instruments to the guiding arm can beaccomplished by using one or more straps, clamps, clasps, magnets, andcombinations thereof.

Examples of instruments that could be attached to the guiding arminclude, but are in no way limited to a cannula, a biopsy needle, aneedle, a tube, a cauterization device, a laser, a drill, an endoscope,a guidewire, a fiberoptic device, an electrode, a saw, an ultrasonicdevice, a spectroscopic device, a camera, an electrical sensor, athermal sensor, a catheter, a draining tube, an imaging device (such asany of those listed and/or described herein) and the like. In certainembodiments, the instrument guided by the inventive apparatusesdescribed herein includes a guide needle and an injection needleconfigured to be concentrically housed therein. In some embodiments, theconcentric arrangement of the guide needle and the injection needleallows the injection needle to be advanced through the guide needle,once the guide needle is properly positioned in a subject during amedical procedure, so that the injection needle can deliver a payload ofbiological or chemical material to an appropriate site in the subject.In some embodiments, the instrument guided and/or stabilized by theinventive apparatus is the spinal multisegmental cell and drug deliverydevice described in U.S. patent application Ser. No. 12/598,667, whichis incorporated by reference herein in its entirety as though fully setforth.

One of skill the art would also readily appreciate that there arenumerous possible ways by which the apparatus can be configured to allowfor an instrument to be extended into and retract from a subject whileconnected to the guiding arm. FIG. 18 depicts one non-limiting exampleof a mechanism that can be used for that purpose. The associationbetween the components shown in FIG. 18 and the function of thosecomponents are thoroughly described in the examples section.

Orientation of Individual Sections

The securing section, connecting section, positioning section andguiding section can be connected to one another by any of a variety ofways depending upon the desired range of motion of each section. In someembodiments, a perpendicular orientation of the positioning arm andconnecting arm, relative to one another, is established through the useof a component with perpendicularly situated clamping collars. In anembodiment, cross clamp 132 (depicted in FIG. 1A) can be used. As shownin FIG. 5, when cross clamp 132 is used to secure positioning arm 2000,knob 114 can be rotated to loosen collar 115, thereby allowing foradjustment of the position of positioning arm 2000 along the x-axis. Asshown in FIG. 8, loosening of collar 115 by rotating knob 114 alsoallows for rotation of positioning arm 2000 along the x-axis, whichtranslates into motion of guiding arm 1000 along the y-z plane.

As shown in FIG. 6, when cross clamp 132 is used to secure connectingarm 3000, rotation of screw 135 loosens lower collar 117, which allowsfor adjustment of the position of positioning arm 2000 along the y-axis.As shown in FIG. 9, loosening collar 117 also allows for rotation ofcross clamp 132 along the y-axis, which in turn translates into motionof guiding arm 1000 along the x-z plane.

Additional Features

The main sections of the stereotactic apparatuses described above can beconfigured to allow for incorporating additional features on theapparatuses. For example, the stereotactic apparatus can include clamps(or any other means of attachment described herein) situated on one ormore of the main sections of the apparatus (i.e. guiding section,positioning section, connecting section, and attaching section) forattaching additional useful instruments or devices.

In certain embodiments, the stereotactic apparatus includes a side clampattached to the securing section, which allows for attaching a usefulinstrument or device. For example, as demonstrated in FIG. 3, side clamp6000 can be used to hold cylindrical device 400. The components of sideclamp 6000 are clearly shown in FIG. 22, and thoroughly described in theexamples section. One of skill in the art would readily appreciate thata side clamp such as side clamp 6000 can be used to attach any of anumber of devices with appropriate dimensions to the stereotacticapparatus.

Devices that can be attached to the stereotactic apparatuses describedherein can include, but are in no way limited to, a pump, a reservoirfor containing a substance to be injected into a subject's body, areservoir for receiving a substance removed from a subject's body, asmall motor, a control panel, an imaging device or portion thereof(including any appropriately sized imaging device described herein) andthe like. In some embodiments, the device attached is a fiber opticcamera that can be positioned to view an opening in a patient's body inwhich a tissue retractor is engaged. In some embodiments, a reservoirattached to the apparatus can be configured to hold any of a variety ofuseful substances, including but in no way limited to cells, gasses,liquids, medications, contrast agents, radioactive materials,combinations thereof, and the like.

An additional category of devices that could be attached to one or moresections of the inventive apparatuses described herein is a lightsource. In various embodiments, the inventive apparatuses may includeone or more light sources configured to project light onto a region ofinterest on or in a subject's body during a medical procedure. In someembodiments, one or more of the light sources is attached to the guidingarm. In some embodiments, the light source is a laser. In someembodiments, the light source is a relatively high energy laser that canbe used for cauterizing or cutting. In some embodiments, the lightsource is a relatively low energy laser that can be used for visuallytargeting a region on or in a subject's body for incision or othermedical intervention. In other embodiments, the light source providesrelatively low energy light for aiding in visualizing a region ofinterest. In still other embodiments, the light source provides light ofa wavelength that causes fluorescence of a fluorophore. In variousembodiments, the fluorophore is introduced into a subject's bodydirectly, present in cells residing in a subject's body, or naturallyoccurring. Merely by way of non-limiting examples, the wavelength of thelight projected by the light source can be in the visible, IR, or UVrange.

Another category of devices that can be incorporated onto thestereotactic apparatuses described herein is an imaging modality. Insome embodiments, the imaging modality is attached to the guiding arm.However, one of skill in the art would recognize that all or a portionof an imaging modality (or any other device described herein, or similarthereto) of an appropriate size could be attached to any arm of theapparatuses described herein, by any form of attachment describedherein. In some embodiments, the imaging modality includes a device usedto perform MRI, CT, or ultrasound imaging. In some embodiments, anendoscope is attached to the guiding arm. In some embodiments, one ormore components of a microscope or other magnifying instrument areattached to the guiding arm. One of skill in the art would readilyappreciate that any of a number of other useful instruments of a sizesuitable for attaching to the guiding arm could be used in conjunctionwith the inventive apparatuses described herein, and attached thereto byany means for attachment described herein.

As indicated above, in some embodiments, the apparatus is configured sothat the positions of the various sections described above can bemanipulated manually. However, one of skill in the art would readilyappreciate that the apparatus could also be configured with one or moremotors, gears, pulleys, and electronic controls, so that one or moresections of the apparatus could be electronically controlled.

In some embodiments, the apparatuses described herein are made ofstainless steel. In some embodiments, the apparatuses are made oftitanium, austenitic steel, martensitic steel, brass, carbon fiber,plastic, combinations thereof, and the like. In preferred embodiments,the material or materials used are biocompatible.

In some embodiments, the invention teaches a method that includes usingany of the stereotactic apparatuses described herein for the purposes offacilitating one or more of the processes of (1) introducing a substanceinto a subject, (2) removing a substance from a subject, and (3)manipulating a portion of a subject's body. One of skill in the artwould readily appreciate that the device could be used to introduce asubstance into and/or remove a substance from any portion of subject'sbody, including, but in no way limited to an organ, joint (shoulder,hip, knee, etc.), ligament, tendon, muscle, eye, cavity, or any othertissue. In some embodiments, the substances introduced into thesubject's body can include but are in no way limited to biologicaland/or synthetic substances. Biological substances can include, but arein no way limited to stem cells, neural progenitor cells, tissues,blood, hormones, clotting factors, vectors (including but not limited toviral vectors, plasmids and the like), DNA, RNA, proteins, growthfactors, inhibitory substances, matrices, combinations thereof, and thelike. Synthetic substances that can be introduced into a subject's bodycan include but are in no way limited to pharmaceutical agents, markers(including but not limited to biomarkers or any other type of markerthat could be visualized with or without the use of imaging equipment),implantable medical devices, electrical sensors, electrical stimulators,glue, sutures, chemotherapeutics, radioactive substances, hyperpolarizedsubstances, combinations thereof, and the like.

Substances that can be removed from a subject's body utilizing theinventive apparatuses and methods include, but are in no way limited to,any of the above-named substances that can be introduced into a subject,in addition to tissues, organs, cancer cells and pre-cancer cells, bonemarrow, fluid, foreign bodies, combinations thereof, and the like.

In some embodiments, the inventive method includes using any of theinventive apparatuses described herein to position any of theinstruments described herein such that they can be introduced betweenthe spreading elements of a retractor device described herein and thenthe adjacent sections of tissue associated therewith. In an embodiment,the inventive method includes using guiding arm 1000 of inventiveapparatus 100 to introduce a needle associated with a cannula into anyportion of a subject's spinal cord (including the section specificallydescribed in the non-limiting examples herein). A payload of neuralprogenitor cells is then advanced through the cannula and needle andinto the subject's spinal cord.

In some embodiments, the invention teaches a method that includes (1)attaching any apparatus described herein to the arm of a retractor, (2)attaching any instrument described herein to the guiding arm of theapparatus (by any means described above), and (3) advancing theinstrument through the separating elements of the retractor and into asubject's body through an incision in the subject's body. FIG. 1D showsa non-limiting example of how the components of an apparatus can besituated to perform this method.

EXAMPLES Example 1 Stereotactic Apparatus with Side Clamp

FIG. 1A depicts exemplary stereotactic apparatus 100. Stereotacticapparatus 100 includes guiding arm 1000, which includes an elongatedchannel 103 situated along its long axis (FIG. 1A). Guiding arm 1000includes a dial 101 and an elongated cylindrical body 102 (FIG. 1A).Guiding arm 1000 also includes instrument attachment component 107, andclamps 105 and 110 which are tightened and loosened by screws 104 and109, respectively (FIG. 1A). The guiding arm 1000 further includesinstrument attachment component guide 108. FIG. 18 depicts an explodedview of guiding arm 1000, in which the assembly of threaded shaft 148,bushing 147, curved spring washer 146, radial ring 145, set screw 144,and dial 101 is shown. FIG. 18 also depicts the assembly of screws 153 aand 153 b, instrument attachment component guide 108 (with screwreceiving holes 152 a and 152 b), cylindrical receiving stopper 151, andscrew 133. FIG. 18 shows instrument attachment component 107 is attachedto sliding carriage 149 through hole 150. FIGS. 10 and 18 show that asdial 101 is turned, intermediate components 145-148 (shown in FIG. 18)cause carriage component 149 to glide along elongated channel 103 (alongthe z-xis), together with instrument attachment component 107. Itfollows that any instrument attached to instrument attachment component107 would also travel along the z-axis when the position of instrumentattachment component 107 is adjusted by rotating dial 101.

FIG. 3 shows an exploded view of stereotactic apparatus 100, in whichthe attachment of guiding arm 1000 to positioning arm 2000 is shown tobe accomplished by securing screw 133 of guiding arm 1000 to receivingsocket 134 of positioning arm 2000. FIG. 3 also shows that positioningarm 2000 traverses a cylindrical opening through upper collar 115 ofcross clamp 132. FIG. 15 shows a partially exploded view of positioningarm 2000, in which the assembly of collar 174, threaded shaft 173,bushing 172, curved spring washer 171, radial ring 170, set screw 169,and dial 116 is shown. FIG. 15 also shows outer nested component 113 andinner nested component 112 of positioning arm 2000. FIG. 16 shows theassembly of inner 112 and outer 113 nesting components of positioningarm 2000. Specifically, screw 175 and set screws 176 a and 176 btraverse outer nested component 113 and inner stabilizing collar 177.The set screws 176 a and 176 b then contact supporting elements 178 aand 178 b, respectively, which in turn rest on the flat portions ofelongated L-shaped grooves 179 a and 179 b, respectively. Thisarrangement allows supporting elements 178 a and 178 b (and screw 175)to constrain motion of inner nesting component 112 of positioning arm2000, and adds to the stability and control of its telescoping motion.Cross-sectional views of positioning arm 2000 are depicted in FIG. 17Aand B.

In addition to guiding arm 1000 and positioning arm 2000, FIG. 3 alsoshows connecting arm 3000 of stereotactic apparatus 100 with outernested element 118 and inner nested element 119. FIG. 3 shows connectingarm 3000 traverses the cylindrical opening of lower collar 117 of crossclamp 132. FIG. 3 also shows that connecting arm 3000 traverses acylindrical opening in clamp 121, and is fastened to end screw 136. Analternate view of these components is demonstrated in FIG. 4. FIG. 4also depicts knob 120 and screw 135, which can each be tightened tosecure connecting arm 3000 in clamp 121 and lower collar 117 (of crossclamp 132), respectively. FIG. 13 shows the assembly of inner 119 andouter 118 nesting components of connecting arm 3000. Screw 168 and setscrews 167 a and 167 b traverse outer nested component 118 and innerstabilizing collar 164. Set screws 167 a and 167 b then contactsupporting elements 166 a and 166 b, respectively, which in turn rest onthe flat portion of elongated L-shaped grooves 165 a and 165 b,respectively. This arrangement allows supporting elements 166 a and 166b (and screw 168) to constrain motion of inner nesting element 119, andadds to the stability and control of its telescoping motion.Cross-sectional views of attaching arm 3000 are depicted in FIG. 14A andB.

FIG. 3 also shows a view of securing arm 4000, which includes clamp 121,body 122, and retractor attaching clamp 5000. Retractor attaching clamp5000 is formed by knob 123, stabilizing screw 126 (which passes throughupper lip 124 of clamp 5000), upper stabilizing arms 125 a and 125 b,and lower stabilizing arms 127 a and 127 b. An exploded view of securingarm 4000 is shown in FIG. 21. In this view, incorporation of set screw162 and rod 161 in the context of the other components of the clamp canbe seen.

FIG. 3 further shows side clamp 6000 of stereotactic apparatus 100. Sideclamp 6000 includes tray arms 128 a and 128 b, and hinged top 129.Hinged top 129 includes an opening through which a portion of an objectclamped by side clamp 6000 (such as elongated object 400 shown inFIG. 1) can be viewed.

Turning now to the various possible adjustments and orientations of thearms (and components thereof) of stereotactic apparatus 100 shown inFIGS. 5-11. FIG. 5 shows rotation of knob 114 loosens upper collar 115of cross clamp 132, thereby allowing adjustment of the position ofpositioning arm 2000 along the x-axis. FIG. 8 shows that rotation ofknob 114 (and associated loosing of upper collar 115 of cross clamp 132)allows for rotation of positioning arm 2000 along the x-axis, whichtranslates into motion of guiding arm 1000 along the y-z plane. FIG. 6shows that rotation of screw 135 results in loosening lower collar 117of cross clamp 132, which allows for adjustment of the position ofpositioning arm 2000 along the y-axis. FIG. 9 shows that rotation ofscrew 135 (and associated loosening of lower collar 117 of cross clamp132) allows for rotation of cross clamp 132 along the y-axis, whichtranslates into motion of guiding arm 1000 along the x-z plane. FIG. 7demonstrates that rotation of knob 130 (and associated loosening of sideclamp component 129) allows for adjustment of the position ofcylindrical object 400 along the x-axis. FIG. 10 shows that rotation ofdial 116 is associated with telescoping of positioning arm 2000 alongthe x-axis. FIG. 10 also shows that rotation of dial 101 is associatedwith motion of instrument attachment component 107 of guiding arm 1000along the z-axis. FIG. 11 shows that rotation of dial 131 is associatedwith telescoping of connecting arm 3000 along the y-axis.

Example 2 Stereotactic Apparatus without Side Clamp

FIGS. 1C and 2C depict stereotactic apparatus 200, which includes thesame components as stereotactic apparatus 100, with the exception of theside clamp 128 depicted in stereotactic apparatus 100. Stereotacticapparatus 200 also functions in the same way as stereotactic apparatus100. with the exception of the functions that relate to side clamp 128.

Example 3 Surgical Procedure

A single level laminectomy can be performed on the L4 vertebral segment.Standard anesthetic/preoperatory techniques are used and the patient ispositioned prone. A 4 cm incision is made at the midline above the L4spinous process. Cutting electrocautery is used to cut the fascia andextend the incision to the spinous process, as well as achievinghemostasis of any small hemorrhages from the incision site. At thispoint a Weitlaner retractor can be used to keep the incision open. Abilateral sub-periosteal dissection is performed carefully by elevatingthe muscles and periosteum off of the lamina. Cutting electrocautery isused to facilitate the dissection. The spinous process is then removedusing a Leksell rongeur. A high-speed drill is used to thin the laminalaterally. The lamina is then lifted and the ligamentous attachment iscut to release the lamina. Kerrison rongeurs are then be used to extendthe laminectomy or clean up any left over bone fragments. In this case,the Medtronic Mast Quadrant retractor system is used. The Weitlanerretractor is removed, and the Mast Quadrant retractor blades areinserted into the incision and attached to the retractor system flexarms. The retractor is opened rostrocaudally to achieve maximum tissuespread. The mediolateral retractor is used in order to keep muscle outof the field. A ˜2.5 cm dura incision is made using an #11 blade and adural guide to prevent spinal cord injury. Using 4-0 Neurolon the durais then tacked at the four corners of the opening to be able tovisualize the nerve roots and facilitate injections. At this point,inventive device 100 is attached to the Mast Quadrant using clamp 5000.Coronal and saggital angles can be adjusted on the device depending onthe spinal cord target using the adjustment mechanisms described above.In this case, the ventral horn is targeted, so a 90-degree (orthogonal)angle of the surgical instrument (needle, cannula, etc) to the spinalcord is established. The surgical instrument (needle, cannula) can nowbe attached to the device. Using the dials of the device, rostrocaudaland mediolateral movement can be achieved to find accurate placement tothe target. The surgical instrument is then positioned into the spinalcord using the ventral rostral movement provided by dial 101 to theappropriate depth. Imaging (CT, MRI, Ultrasound, and the like) can beused to help position the device in all planes (coronal and saggitalangle, rostrocaudal, mediolateral and dorsoventral positioning). Whenthe surgical instrument (needle) is in position, the therapeutic agent(neural progenitor cells) can be infused into the spinal cord target.The surgical instrument is then returned to the starting position andcan then be repositioned for subsequent injections. Once all of theinjections/infusions are completed, the surgical instrument can beremoved, followed by the device. The dura tacks can then be cut and theretractor system removed. The incision can then be closed in fourlayers. The dura is closed with a running stitch using a 4-0 neurolon.Once it's closed, a valsalva maneuver can be performed to ensure it'swatertight and there's no cerebrospinal fluid leakage. The deep musclelayer is closed with a 0 Vycril suture as well as the Muscle fascia. Thedermal layer is closed using a 3-0 vycril and finally the skin is closedusing a locked running stitch with 2-0 nylon.

The various methods and techniques described above provide a number ofways to carry out the invention. Of course, it is to be understood thatnot necessarily all objectives or advantages described can be achievedin accordance with any particular embodiment described herein. Thus, forexample, those skilled in the art will recognize that the methods can beperformed in a manner that achieves or optimizes one advantage or groupof advantages as taught herein without necessarily achieving otherobjectives or advantages as taught or suggested herein. A variety ofalternatives are mentioned herein. It is to be understood that someembodiments specifically include one, another, or several features,while others specifically exclude one, another, or several features,while still others mitigate a particular feature by inclusion of one,another, or several advantageous features.

Furthermore, the skilled artisan will recognize the applicability ofvarious features from different embodiments. Similarly, the variouselements, features and steps discussed above, as well as other knownequivalents for each such element, feature or step, can be employed invarious combinations by one of ordinary skill in this art to performmethods in accordance with the principles described herein. Among thevarious elements, features, and steps some will be specifically includedand others specifically excluded in diverse embodiments.

Although the application has been disclosed in the context of certainembodiments and examples, it will be understood by those skilled in theart that the embodiments of the application extend beyond thespecifically disclosed embodiments to other alternative embodimentsand/or uses and modifications and equivalents thereof.

In some embodiments, the terms “a” and “an” and “the” and similarreferences used in the context of describing a particular embodiment ofthe application (especially in the context of certain of the followingclaims) can be construed to cover both the singular and the plural. Therecitation of ranges of values herein is merely intended to serve as ashorthand method of referring individually to each separate valuefalling within the range. Unless otherwise indicated herein, eachindividual value is incorporated into the specification as if it wereindividually recited herein. All methods described herein can beperformed in any suitable order unless otherwise indicated herein orotherwise clearly contradicted by context. The use of any and allexamples, or exemplary language (for example, “such as”) provided withrespect to certain embodiments herein is intended merely to betterilluminate the application and does not pose a limitation on the scopeof the application otherwise claimed. No language in the specificationshould be construed as indicating any non-claimed element essential tothe practice of the application.

Certain embodiments of this application are described herein, includingthe best mode known to the inventors for carrying out the application.Variations on those embodiments will become apparent to those ofordinary skill in the art upon reading the foregoing description. It iscontemplated that skilled artisans can employ such variations asappropriate, and the application can be practiced otherwise thanspecifically described herein. Accordingly, many embodiments of thisapplication include all modifications and equivalents of the subjectmatter recited in the claims appended hereto as permitted by applicablelaw. Moreover, any combination of the above-described elements in allpossible variations thereof is encompassed by the application unlessotherwise indicated herein or otherwise clearly contradicted by context.

All patents, patent applications, publications of patent applications,and other material, such as articles, books, specifications,publications, documents, things, and/or the like, referenced herein arehereby incorporated herein by this reference in their entirety for allpurposes, excepting any prosecution file history associated with same,any of same that is inconsistent with or in conflict with the presentdocument, or any of same that may have a limiting affect as to thebroadest scope of the claims now or later associated with the presentdocument. By way of example, should there be any inconsistency orconflict between the description, definition, and/or the use of a termassociated with any of the incorporated material and that associatedwith the present document, the description, definition, and/or the useof the term in the present document shall prevail.

In closing, it is to be understood that the embodiments of theapplication disclosed herein are illustrative of the principles of theembodiments of the application. Other modifications that can be employedcan be within the scope of the application. Thus, by way of example, butnot of limitation, alternative configurations of the embodiments of theapplication can be utilized in accordance with the teachings herein.Accordingly, embodiments of the present application are not limited tothat precisely as shown and described.

1. An apparatus, comprising: a securing arm comprising a first end, asecond end, a long axis, and a short axis; a connecting arm comprising afirst end, a second end, a long axis, and a short axis; a positioningarm comprising a first end, a second end, a long axis, and a short axis;and a guiding arm comprising a first end, a second end, a long axis, anda short axis; wherein (1) the first end of the connecting arm isattached to the second end of the securing arm, (2) the second end ofthe connecting arm is attached to the first end of the positioning arm,(3) the long axis of the connecting arm is perpendicular to the longaxis of each of the securing arm and positioning arm, (4) the first endof the securing arm and the second end of the positioning arm can bepositioned to extend in substantially the same direction away from theconnecting arm, (5) the positioning arm is attached at its second end tothe second end of the guiding arm, such that the positioning arm andguiding arm are perpendicular to one another, and (6) the guiding armcan be positioned such that the axis along which its long axis issituated is perpendicular to but does not intersect with the axes alongwhich the long axis of the securing arm and the long axis of theconnecting arm are respectively situated.
 2. The apparatus of claim 1,wherein the securing arm further comprises one or more clamps on itsfirst end, and wherein the one or more clamps are configured to attachto an arm of a tissue retractor.
 3. The apparatus of claim 2, whereinthe guiding arm further comprises an instrument attaching componentconfigured to slide along the long axis of the guiding arm.
 4. Theapparatus of claim 3, wherein the instrument attaching componentcomprises one or more clamps configured to clamp a medical instrument.5. The apparatus of claim 4, wherein the sliding motion of theinstrument attaching component is controlled by a dial situated at thefirst end of the guiding arm.
 6. The apparatus of claim 5, wherein theconnecting arm comprises elongated nesting elements that allow fortelescoping motion in the direction of its long axis, such that thelength of the connecting arm can be increased or decreased.
 7. Theapparatus of claim 6, wherein the positioning arm comprises elongatednesting elements that allow for telescoping motion in the direction ofits long axis, such that the length of the positioning arm can beincreased or decreased.
 8. The apparatus of claim 7, wherein thetelescoping motion of the connecting arm is controlled by rotation of adial situated at its second end.
 9. The apparatus of claim 8, whereinthe telescoping motion of the positioning arm is controlled by rotationof a dial situated at its first end.
 10. The apparatus of claim 9,wherein the medical instrument is selected from the group consisting of:a cannula, a biopsy needle, a needle, a tube, a cauterization device, alaser, a drill, an endoscope, a guidewire, a fiberoptic device,electrode, a saw, an ultrasonic device, a spectroscopic device, acamera, an electrical sensor, a thermal sensor, a catheter, a drainingtube, and combinations thereof.
 11. The apparatus of claim 10 furthercomprising a side clamp attached to the securing arm, wherein the sideclamp is configured to attach to an elongated object.
 12. The apparatusof claim 11, wherein the securing arm is removably attached to theconnecting arm.
 13. The apparatus of claim 12, wherein the positioningarm is removably attached to the connecting arm and/or the guiding arm.14. The apparatus of claim 13, wherein the side clamp is removablyattached to the securing arm.
 15. The apparatus of claim 14, wherein theelongated object is a device selected from the group consisting of: aliquid reservoir, a gas reservoir, a pump, an imaging device, andcombinations thereof.
 16. A system, comprising the apparatus of claim 10and a tissue retractor attached to the securing arm of the apparatus byone or more clamps of the securing arm.
 17. The system of claim 16,further comprising an instrument attached to the instrument attachingcomponent, wherein the instrument is selected from the group consistingof: a cannula, a biopsy needle, a needle, a tube, a cauterizationdevice, a laser, a drill, an endoscope, a guidewire, a fiberopticdevice, electrode, a saw, an ultrasonic device, a spectroscopic device,a camera, an electrical sensor, a thermal sensor, a catheter, a drainingtube, and combinations thereof.
 18. The system of claim 17, wherein theinstrument comprises a cannula with a needle situated at the endthereof.
 19. The system of claim 18, wherein the cannula and needle areconfigured to inject cells into a region of interest in a subject'sbody.
 20. The system of claim 19, wherein the cannula contains aquantity of neural progenitor cells.
 21. The system of claim 20, whereinthe neural progenitor cells express glial cell line derived neurotrophicfactor.
 22. The system of claim 21, wherein the region of interest isthe subject's spine.
 23. The system of claim 22, further comprising aliquid reservoir and a pump connected thereto, wherein the liquidreservoir and pump are attached to the side clamp.
 24. A method forperforming a surgical procedure on a subject, comprising attaching theapparatus of claim 15 to an arm of a tissue retractor that is engaged inan incision in the subject's body, and guiding a medical instrumentattached to the guiding arm of the apparatus through the incision in thesubject's body.
 25. The method of claim 24, wherein the medicalinstrument is a cannula with a needle situated at the end thereof. 26.The method of claim 25, wherein the cannula and needle are configured toinject cells into a region of interest in the subject's body.
 27. Themethod of claim 26, wherein the region of interest is the subject'sspine.
 28. The method of claim 27, wherein the cells are neuralprogenitor cells.
 29. The method of claim 28, wherein the subject hasbeen diagnosed with amyotrophic lateral sclerosis (ALS).
 30. The methodof claim 29, further comprising performing imaging of the region ofinterest in the subject's body.
 31. The method of claim 28, wherein theimaging performed is selected from the group consisting of computedtomography (CT), magnetic resonance imaging (MRI), ultrasound, andcombinations thereof.
 32. The method of claim 29, further comprisinginjecting neural progenitor cells expressing glial cell line derivedneurotrophic factor into the subject's spine.